Health Maintenance Reminders Research Articles

1172. Compliance with Human Papillomavirus Vaccination At The HIV Outpatient Program in New Orleans, Louisiana

Abstract Background Guidelines recommend the human papillomavirus (HPV) vaccine for all adults through age 26, shared clinical decision-making for those aged 27 through 45 years who are inadequately vaccinated, and for all people with HIV up to age 45 years. The intent of this study is to evaluate HPV vaccination rates at the HIV Outpatient Program (HOP) at University Medical Center in New Orleans. Methods Immunization records from patients aged 18 through 45 years attending a physician visit in the LSU Infectious Diseases fellows’ HIV primary care clinic at HOP in 2022 were reviewed. The purpose of this project was to assess compliance with HPV vaccination recommendations among the infectious diseases fellows. Results Among patients under age 27, 15 of 21 visits (71%) had completed HPV vaccines series. 4 visits (19%) had incomplete status and 2 visits (10%) did not have any HPV vaccines record. Among patients aged 27 through 45 years, 73 of 194 visits (38%) had completed HPV vaccines series. 34 visits (18%) had partial vaccination records and 87 visits (45%) had no records. Conclusion Vaccination compliance among the LSU ID fellows was less than ideal, only 71% of visits for patient aged up to 27 years attending LSU ID fellows’ clinic had completed HPV vaccine series, compared to the Health People 2020 recommendation of 80%. Only 38% of visits for patients aged 27 through 45 years are fully vaccinated with HPV vaccines. Patients in this age group are often labeled “aged out” for HPV vaccines by health maintenance reminders however, due to having HIV, they are still eligible and should be vaccinated. These results led to the institution of quality improvement project to address HPV vaccinations. This intervention will focus on educating all HOP providers about the vaccination recommendations and updating the health maintenance care gaps reminder in the electronic medical record. Disclosures All Authors: No reported disclosures

Integrated Health Maintenance Reminders for Improved HPV Vaccine Administration: TowardImprovements in Completion Disparities.

To evaluate the effect of a health maintenance reminder (HMR) on human papillomavirus (HPV) vaccine administration and completion across different age, insurance, and race cohorts. Retrospective pre-post analysis. Academic primary care. Patients aged 9 to 26 who had initiated the HPV vaccine series from 2016 to 2021 were analyzed, based on current age-based standards. The cohort was divided based on vaccine uptake before and after the implementation of the HMR program in February 2020. The multivariate analysis estimated the odds of vaccine completion based on sociodemographic factors, and variable interactions were investigated to determine independent associations between sociodemographic factors and HMR implementation. There were 7654 individual patients (mean age was 15.8 years; 46.7 were males; and 50.7% were white). HPV vaccine completion rates increased post-HMR implementation by 59.2% (37% pre-, and 58.9% post-HMR; p < .001) in the entire cohort. Overall, black patients (adjusted odds ratio [aOR] = 0.68; 95% confidence interval [CI]: 0.60, 0.70) and patients ≥18 years (aOR = 0.13; 95% CI: 0.11, 0.15) were significantly less likely to complete their vaccine series; however, this improved significantly following HMR in these groups (p < .001). Post-HMR, race, and insurance status were not independently associated with disparate vaccine completion rates, however,age was, and patients ≤14 or younger had higher odds of vaccine completion (aOR = 3.54; 95% CI: 2.91, 4.32). The implementation of an HMR was associated with increased HPV vaccine uptake across age and race groups in this single-institution study. Future research should explore barriers to implementing HMRs in different health care settings.

Effects of Behavioral Economics-Based Messaging on Appointment Scheduling Through Patient Portals and Appointment Completion: Observational Study.

BackgroundBehavioral economics–based techniques have been an increasingly utilized method in health care to influence behavior change by modifying language in patient communication (through choice architecture and the framing of words). Patient portals are a key tool for facilitating patient engagement in their health, and interventions deployed via patient portals have been effective in improving utilization of preventive health services.ObjectiveWe examined the impacts of behavioral economics–based nudge health maintenance reminders on appointment scheduling through a patient portal and appointment completion for 2 preventive services: Medicare wellness visits and Pap smear.MethodsWe conducted a retrospective observational study using electronic health record data from an integrated health care system in Northern California. Nudge health maintenance reminders with behavioral economics–based language were implemented for all sites in November 2017 for Medicare wellness visits and for selected sites in February 2018 for Pap smears. We analyzed 125,369 health maintenance reminders for Medicare wellness visits, and 585,358 health maintenance reminders for Pap smear sent between January 2017 and February 2020. The primary outcomes were rate of appointments scheduled through the patient portal and appointment completion rate. We compared the outcomes between those who received the new, behavioral economics–based health maintenance reminders (the nudge group) and those who received the original, standard health maintenance reminders (the control group). We used segmented regression with interrupted time series to assess the immediate and gradual effect of the nudge for Medicare wellness visits, and we used logistic regression to assess the association of nudge health maintenance reminders, adjusting for the propensity to receive a nudge health maintenance reminder, for Pap smear.ResultsThe rates of appointments scheduled through the patient portal were higher for nudge health maintenance reminder recipients than those for control health maintenance reminder recipients (Medicare wellness visits—nudge: 12,537/96,839, 13.0%; control: 2,769/28,530, 9.7%, P<.001; Pap smear—nudge: 8,239/287,149, 2.9%; control: 1,868/120,047, 1.6%; P<.001). Rates of appointment completion were higher for nudge health maintenance reminders for Pap smear (nudge: 67,399/287,149, 23.5% control: 20,393/120,047, 17.0%; P<.001) but were comparable for Medicare wellness visits (nudge: 49,835/96,839, 51.5% control: 14,781/28,530, 51.8%; P=.30). There was a marginally gradual effect of nudge on number of appointments scheduled through the patient portal for the overall Medicare wellness visits sample (at a monthly rate of 0.26%, P=.09), and a significant gradual effect among scheduled appointments (at a monthly rate of 0.46%, P=.04). For Pap smear, nudge health maintenance reminders were positively associated with number of appointments scheduled through the patient portal (overall sample: propensity adjusted odds ratio [OR] 1.62; 95% CI 1.50-1.74; among scheduled appointments: propensity adjusted OR 1.61, 95% CI 1.47-1.76) and with appointment completion (propensity adjusted OR 1.07; 1.04-1.10).ConclusionsNudges, a behavioral economics–based approach to providing health maintenance reminders, increased the number of appointments scheduled through the patient portal for Medicare wellness visits and Pap smear. Our study demonstrates that a simple approach—framing and modifying language in an electronic message—can have a significant and long-term impact on patient engagement and access to care.

Using Preventive Health Alerts in the Electronic Health Record Improves Hepatitis C Virus Testing Among Infants Perinatally Exposed to Hepatitis C.

Perinatal exposure to hepatitis C virus (HCV) is a major public health issue, and poor testing rates leave many children with infection unidentified. We sought to use the electronic health record (EHR) to promote guideline-directed HCV testing among infants born to mothers with HCV infection in an urban, safety-net hospital system. Our study population was identified using our EHR database, Epic. Children were included in the study if they had perinatal HCV exposure, were 18 months to 18 years of age and had at least 1 encounter in a primary or urgent care clinic during the study period. Our study included retrospective (October 2011 to February 2015) and prospective (February 2015 to May 2018) arms. Our EHR-based intervention was initiated in the prospective arm and recommended a one-time HCV antibody test at or after the age of 18 months using a health maintenance reminder. The health maintenance reminder activated a point-of-care alert and a linked HCV testing order set in all prespecified encounters during the intervention period. Median time to appropriate HCV testing decreased from 96.2 months preintervention to 9.1 months postintervention (P < 0.0001), and rate of completed antibody testing increased from 14% to 61% (P < 0.0001). Among children with perinatal HCV exposure, using a point-of-care alert within the EHR significantly increased the HCV antibody testing rate in accordance with American Academy of Pediatrics (AAP) recommendations. More effective EHR-based interventions combined with increased provider awareness of appropriate HCV testing in perinatally exposed infants is imperative.

1165 Improving the Accuracy of Health Maintenance Reminders in the Electronic Medical Record to Promote Adherence to Colonoscopy Surveillance Guidelines

INTRODUCTION: Health Maintenance (HM) reminders in the Epic electronic medical record (EMR) offer an opportunity to increase adherence to recommended colonoscopy surveillance intervals. However, HM reminders must be updated by providers with specific knowledge of surveillance guidelines, and providers must be comfortable using the HM functionality. This quality improvement initiative aimed to improve the rate at which gastroenterologists accurately update HM colonoscopy surveillance recommendations. METHODS: 1,602 colonoscopies performed by 7 gastroenterologists at a single community hospital were tracked prospectively between April 2018–February 2019. For each colonoscopy, the gastroenterologist’s post-procedure surveillance recommendation was compared to the HM surveillance recommendation in the patient’s Epic EMR. Accuracy was defined as concordance between these two recommendations. After obtaining baseline data, group and individual performance rates were disseminated and the gastroenterologists underwent an educational intervention to improve familiarity with the HM functionality. Monthly HM accuracy rates were tracked for the subsequent 6 months. Accuracy rates in the post-intervention month and the last month of follow-up were compared to baseline using the student’s T-test. RESULTS: The baseline HM accuracy rate for the group was 69% overall and 56% for high-risk patients (defined as a recommended surveillance interval of ≤5 years). For the month immediately following the intervention, the overall accuracy rate rose significantly compared to baseline (86% vs 69% overall, P ≤ 0.001; 80% vs 56% for high-risk patients, P ≤ 0.001). However, for the last month of follow-up the overall accuracy rate had decreased back to baseline (70% vs 69%, P = 0.646). The high-risk accuracy rate in the last month remained significantly higher than baseline but had also declined (65% vs 56%, P = .008). Notably, 82% of discordant HM reminders recommended a longer surveillance interval than was clinically indicated. CONCLUSION: Sharing performance data and provider education can significantly improve the rate at which gastroenterologists accurately update colonoscopy HM surveillance intervals in the EMR. However, a single intervention is not sufficient to sustain this improvement over time. Repeated intervention is needed to ensure that HM surveillance intervals remain accurate, particularly since the majority of discordant HM reminders recommend a longer surveillance interval than is clinically indicated.

A survey of factors affecting clinician acceptance of clinical decision support

BackgroundReal-time clinical decision support (CDS) integrated into clinicians' workflow has the potential to profoundly affect the cost, quality, and safety of health care delivery. Recent reports have identified a surprisingly low acceptance rate for different types of CDS. We hypothesized that factors affecting CDS system acceptance could be categorized as relating to differences in patients, physicians, CDS-type, or environmental characteristics.MethodsWe conducted a survey of all adult primary care physicians (PCPs, n = 225) within our group model Health Maintenance Organization (HMO) to identify factors that affect their acceptance of CDS. We defined clinical decision support broadly as "clinical information" that is either provided to you or accessible by you, from the clinical workstation (e.g., enhanced flow sheet displays, health maintenance reminders, alternative medication suggestions, order sets, alerts, and access to any internet-based information resources).Results110 surveys were returned (49%). There were no differences in the age, gender, or years of service between those who returned the survey and the entire adult PCP population. Overall, clinicians stated that the CDS provided "helps them take better care of their patients" (3.6 on scale of 1:Never – 5:Always), "is worth the time it takes" (3.5), and "reminds them of something they've forgotten" (3.2). There was no difference in the perceived acceptance rate of alerts based on their type (i.e., cost, safety, health maintenance). When asked about specific patient characteristics that would make the clinicians "more", "equally" or "less" likely to accept alerts: 41% stated that they were more (8% stated "less") likely to accept alerts on elderly patients (> 65 yrs); 38% were more (14% stated less) likely to accept alerts on patients with more than 5 current medications; and 38% were more (20% stated less) likely to accept alerts on patients with more than 5 chronic clinical conditions. Interestingly, 80% said they were less likely to accept alerts when they were behind schedule and 84% of clinicians admitted to being at least 20 minutes behind schedule "some", "most", or "all of the time".ConclusionEven though a majority of our clinical decision support suggestions are not explicitly followed, clinicians feel they are of benefit and would be even more beneficial if they had more time available to address them.

Providers' reactions to an automated health maintenance reminder system incorporated into the patient's electronic medical record.

Automated health maintenance reminder (HMR) systems embedded in electronic medical records systems have been found to improve utilization of preventive services, but underuse persists. Our goal was to learn how to make HMRs more effective by measuring clinicians' self-reported use of HMRs and attitudes toward an HMR system embedded in an electronic medical record. We surveyed 43 clinicians using an electronic medical record with an automated HMR system that prompted the provision of preventive or screening interventions. We measured general attitudes toward computers and the HMR, attitudes toward health maintenance, reactions to key features of the HMR system, and use of information provided by the HMR system; and we asked open-ended responses on how to improve the system. Seventy-five percent of clinicians reported not observing or paying attention to the HMR flashing reminder icon when reviewing a chart, and 62.8% reported they either ignored or forgot to address an alert when it appeared. Only 20% reported regularly reviewing health maintenance needs of the patient before the clinical encounter, and 56% reported seldom or never acting on HMR information during an encounter that was not health maintenance. This HMR system embedded in an electronic medical record was underused by clinicians, causing lost opportunities for provision of preventive care. As electronic medical records become more common, we need to find practical ways that are acceptable to clinicians to use the new capabilities the systems provide.

Half a Loaf Is Better Than Waiting for the Bread Truck

We describe a locally developed system for partial computer storage of medical data, called the mini-medical record system. The system produces a typed face sheet prior to each patient visit. The face sheet, which also serves as a progress note, contains patient demographic data, medical problem lists, previous vital signs, allergies, medication profile, and health maintenance reminders. Between regularly scheduled visits, all computerized data are available by computer printout for unscheduled visits to walk-in clinics and the emergency department. Structured reports are generated by the system that describes each resident and faculty members' practice. Quality assurance reports are also available. Since the system draws from several already existing databases, new data entry requirements are modest and cost to the institution is low. Partially computerized systems can be developed inexpensively and are well received in multispecialty practices, where interphysician communication is vital.

The Effect of Patient-Carried Reminder Cards on the Performance of Health Maintenance Measures

We designed a card that patients carried and showed to their physicians at scheduled appointments to remind them to perform six health maintenance procedures: influenza vaccination, pneumococcal vaccination, rectal examination and hemoccult test, Papanicolaou's smear, physician breast examination, and mammography. Prompt sheets were also attached to all charts to remind physicians to perform these same procedures. One hundred seventy-five patients received the card and the physician prompt sheets on their charts. Two hundred forty-eight patients received only physician's prompt sheet. The card group had significant increases in the performance of influenza vaccinations (47% vs 29%), rectal examination and hemoccult tests (59% vs 46%), Papanicolaou's smears, (30% vs 20%), and physician breast examinations (52% vs 29%). There was not a significant increase in the performance of pneumococcal vaccines (22% vs 24%) or mammography (18% vs 19%). We conclude that patient-carried health maintenance reminder cards are useful in increasing the physician performance of influenza vaccinations, rectal examinations and hemoccult tests, Papanicolaou's smears, and breast examinations.

A Nurse-Initiated Reminder System for the Periodic Health Examination

Implementation of specific health maintenance recommendations into practice settings has been difficult. We introduced a nurse-initiated health maintenance reminder system into a university-based internal medicine practice setting. We then compared performance of selected items (Papanicolaou smear, stool examination for occult blood, breast examination, and influenza immunization) in the practice before and after institution of the system. The system required no additional personnel and was quickly learned by the nursing staff. There were significant increases in the performance of stool examination for occult blood (32% to 47%), breast examination (29% to 46%), and influenza immunization (18% to 40%) after the reminder system was introduced. A nurse-initiated health maintenance reminder system is a feasible and effective method for implementing periodic health examination procedures into a practice setting.